In recent years, transcatheter edge-to-edge mitral valve repair (E2E-MVR) using the mitral clip approach (MitraClip, Abbott Vascular, Menlo Park, California, USA) has evolved as the predominant alternative non-surgical treatment option for patients with symptomatic mitral regurgitation (MR) who were judged inoperable by a heart team. By now, more than 45 000 patients have been treated with this approach, demonstrating a wide acceptance for this interventional treatment.

MR is classified on the basis of the underlying aetiology as primary (degenerative) or secondary (functional) that constitute markedly different diseases. In patients with primary MR, the mitral valve apparatus per se is diseased and left ventricular ejection fraction (LV-EF) is mostly preserved (mean LV-EF of 58% in Chiarito et al's Heart manuscript).1 The Endovascular Valve Edge-to-Edge Repair Study (EVEREST) II2—which included predominantly patients with primary MR (in 73% of randomised patients)—E2E-MVR did not reduce MR as effectively as surgical mitral valve repair or replacement in patients who were eligible for surgery, but nevertheless, short-term clinical outcome of patients treated with E2E-MVR showed a similar mortality rate and improvement of New York Heart Association (NYHA) functional class compared with surgical mitral valve repair and replacement. Although the inferior MR reduction was initially thought of as disappointing, the overall results may also be considered favourably due to the fact that the interventional experience with E2E-MVR was negligible in this early trial with a mean experience of less than 10 cases per interventional site. The 5-year result of the EVEREST II trial showed no difference in mortality and a comparable symptomatic improvement between E2E-MVR and surgical mitral valve repair and replacement. Both American and European guidelines advise E2E-MVR for patients with a prohibitive surgical risk due to severe comorbidities with chronic severe primary MR who have favourable anatomy for the repair procedure and a …

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